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MEDICARE 

Coverage of Kidney 
Dialysis and Kidney 
Transplant Services 



A Supplement to Your Medicare Handbook 



PUBS 

RA 

645 

K5 

M43 

1995 





U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 
HEALTH CARE FINANCING ADMINISTRATION 



-:i::iv;5ro, Maryjgnd 21244 



J 



Contents — 

1 75100 Security Blvd. 

Medicare and Treatment for Permanent Kidney Failure 1 

The Two Parts of Medicare 1 

Hospital Insurance (Part A) 1 

Medical Insurance (Part B) 2 

Enrollment in Medicare for People with Permanent Kidney Failure 2 

When Medicare Protection Begins 2 

When Medicare Protection Ends 3 

Medicare Payment for Beneficiaries Covered by 

Employer Group Health Plans 3 

Providers of Maintenance Dialysis and Transplant Surgery 4 

Coverage of Maintenance Dialysis 4 

Outpatient Dialysis 4 

Inpatient Dialysis 4 

Doctor's Services and 

Maintenance Dialysis 5 

Outpatient Doctor's Services 5 

Inpatient Doctor's Services 5 

Self-Dialysis Training 5 

Home Dialysis 5 

Payment Options Under Home Dialysis 6 

Method I: The Composite Rate 6 

Method H: Dealing Directly with a Supplier 6 

Home Dialysis Equipment 6 

Home Dialysis Supplies 6 

Home Dialysis Support Services 6 

Kidney Transplant Surgery 7 

What Hospital Insurance (Part A) Pays For 7 

What Medical Insurance (Part B) Pays For 7 

How Medicare Pays for Blood 7 

What Medicare Does Not Cover g 

Other Payment Sources 8 

If You Have a Complaint g 

For Additional Help g 

ESRD Network Organizations 9 



Medicare and Treatment for 
Permanent Kidney Failure 

This supplement to Your Medicare Handbook 
explains the special rules that apply to Medicare 
coverage and payment for maintenance kidney 
dialysis and transplant services. People who have 
permanent kidney failure (End Stage Renal 
Disease or ESRD) can get these services. 

Medicare also helps pay for a wide range of 
other health services and supplies. Your Medicare 
Handbook describes the other health services and 
supplies that are covered by Medicare and how 
payments are made. If you don't have a copy of 
the Handbook, you can get one from Social 
Security. 

The Two Parts of Medicare 

Medicare has two parts — hospital insurance 
(Part A) and medical insurance (Part B). This 
section briefly describes each part. For more 
detailed information, see Your Medicare 
Handbook. 

Hospital Insurance (Part A) 

Hospital care: Medicare Part A covers 
medically necessary inpatient hospital care. Part 
A, for example, helps pay for an inpatient stay in 
an approved hospital for kidney transplant 
surgery. 



Medicare helps pay for up to 90 days of 
medically necessary inpatient hospital care in 
each benefit period. Medicare will help pay for 
more days if you use all or some of your lifetime 
reserve days. (See below for an explanation of 
benefit periods and lifetime reserve days.) 

From the first day through the 60th day in a 
hospital during each benefit period, Part A pays 
for all covered services except the Part A 
deductible. From the 61st through the 90th day 
in a hospital during each benefit period, Part A 
pays for all covered services except for a daily 
amount called Part A coinsurance. If you need 
to stay in the hospital longer than 90 days, you 
may choose to use reserve days. 

Skilled nursing facility care: Under certain 
conditions, Medicare Part A helps pay for 100 
days of post-hospital care in a skilled nursing 
facility per benefit period. No deductible is 
required and you pay no coinsurance for the first 
20 days. You pay a coinsurance amount each 
day for the 21st through the 100th day of care. 

Home health care: Medicare Part A helps pay 
for medically necessary home health care. There 
is no Medicare deductible for home health care. 
You pay no home health care coinsurance, except 
for 20 percent of the approved amount for durable 
medical equipment. 

Hospice care: Medicare Part A helps pay for 
up to 210 days of hospice care. When necessary, 
an extended period of coverage may be allowed. 



Benefit periods: The benefit period is a way of 
measuring your use of inpatient hospital and skilled 
nursing facility services under Medicare Part A. 

Your first benefit period starts the first time you 
enter a hospital after your hospital insurance 
begins. A benefit period ends when you have 
been out of a hospital or other facility primarily 
providing skilled nursing or rehabilitation services 
for 60 days in a row (including the day of 
discharge). If you remain in a facility (other than 
a hospital) that primarily provides skilled nursing 
or rehabilitative services, a benefit period ends 
when you have not received any skilled care there 
for 60 days in a row. 

There is no limit to the number of benefit periods 
you can have for hospital and skilled nursing 
facility care. 



Reserve days: Medicare Part A includes 
an extra 60 hospital days you can use if 
you have a long illness and have to stay 
in the hospital for more than 90 days. 
These extra days are called reserve days. 
You have only 60 reserve days in your 
lifetime, and you can decide when you 
want to use them. The lifetime reserve 
days are nonrenewable. 



1 



You pay no deductible; you pay a small 
coinsurance amount for outpatient drugs and 
respite care. 

Medicare payments: Medicare payments for 
services covered by Part A are made directly to 
the participating hospital, skilled nursing facility, 
home health agency, and hospice. 

Medical Insurance (Part B) 

Medicare Part B covers doctor's services, 
outpatient hospital services, outpatient physical 
therapy and speech pathology services, and many 
other health services and supplies. 

Most of the services and supplies needed by 
people with permanent kidney failure are covered 
by Part B. For example, Part B covers outpatient 
maintenance dialysis, staff-assisted dialysis, self- 
dialysis training, and home dialysis. Part B has 
premiums, deductibles and coinsurance amounts 
that you must pay yourself or through coverage 
by another insurer. 

The first $100 in covered expenses is called 
the Part B deductible. You need to meet this 
$100 deductible only once during the year. The 
deductible can be met by any combination of 
covered expenses. You do not have to meet a 
separate deductible for each different kind of 
covered service you receive. 

The deductible applies to your expenses for 
doctors, providers and suppliers. Suppliers are 
people or organizations other than doctors or 
health care facilities that furnish equipment or 
services covered by Part B. 

After you have paid $100 in Medicare- 
approved charges for covered medical expenses, 
Part B generally pays 80 percent of the approved 
charges for any additional covered services you 
receive during the rest of the year. You are 
responsible for the remaining 20 percent-your 
coinsurance. 

See page 7 for more information about 
Medicare Part B payments. 

Enrollment in Medicare for People 
with Permanent Kidney Failure 

You are eligible for Medicare Part A regardless 
of your age if: 

• You require regular dialysis or have had a 
kidney transplant, and 



• You, your spouse or dependent child get Social 
Security cash benefits or have worked the 
required amount of time (usually 10 years) to 
qualify. 

You can enroll at your local Social Security 
office. You may also want to enroll in Medicare 
Part B when you enroll for Part A. 

If you have had Medicare before you 
developed permanent kidney failure and have not 
signed up for Part B or if your Part B has stopped, 
you can apply for this protection now. If you 
already have Part B but are paying a premium 
penalty for late enrollment, your premium amount 
can be reduced to the current basic rate. Social 
Security can give you more information. 

When Medicare Protection Begins 

When you are first enrolled in Medicare 
because of permanent kidney failure, your 
Medicare protection starts with the 3rd month 
after the month your course of maintenance 
dialysis treatments began. For example, if you 
began receiving maintenance dialysis treatments 
in July, your Medicare coverage would start on 
October 1. 

There are tv/o ways your Medicare protection 
can begin earlier. 

• Medicare coverage can begin in the first month 
of dialysis if: 

— you participate in a self-dialysis training 
program in a Medicare-approved training 
facility, 

— you start the training before the third month 
after dialysis begins, and 

— you expect to complete the training and 
self-dialyze after that. 

• Medicare coverage can begin the month you are 
admitted to an approved hospital for a kidney 
transplant or procedures preliminary to a 
transplant if: 

— the transplant takes place in that month or 
within the two following months. 

If your transplant is delayed more than two 
months after you are admitted to the hospital for 
the transplant or procedures preliminary to the 
transplant, Medicare will begin two months before 
the month of the transplant. 



When Medicare Protection Ends 

If you have Medicare only because of 
permanent kidney failure, Medicare protection 
will end 12 months after the month you no longer 
require maintenance dialysis treatments or 36 
months after the month of a kidney transplant. 

Note: Medicare coverage may be reinstated 
immediately without any waiting period if: 

• You resume dialysis or get a transplant within 
the 12 month period after the month you 
stopped getting dialysis, or 

• You begin or resume dialysis or get another 
transplant within the 36-month period after a 
transplant. 

Your Medicare Part B can stop at any time if 
you fail to pay premiums or if you decide to 
cancel it. 

Medicare Payment for 
Beneficiaries Covered by 
Employer Group Health Plans 

Some Medicare beneficiaries are also covered 
by an employer group health plan. For these 
Medicare beneficiaries the employer plan is often 
the primary plan — that is, the employer plan pays 
first on the Medicare beneficiary's health 
insurance claims. 

If you can get Medicare because of permanent 
kidney failure and are covered by an employer 
group health plan, Medicare will be your 
secondary payer during an 18-month coordination 
period. The 18-month coordination period applies 
to employer coverage based on your or a family 
member's employment as well as to employer 
coverage based on retirement. 

The 18-month period in which Medicare is 
secondary begins the first month you are able to 
get Medicare because of permanent kidney 
disease — whether or not you are enrolled. The 
18-month coordination period applies, even for 
those people already enrolled in Medicare because 
of age or disability. However, if before you 
became eligible for Medicare based on permanent 
kidney failure, you were already entitled to 
Medicare based on age or disability and your 
employer plan has already taken your age or 
disability entitlement into account, such as by 



paying secondary to Medicare, it may continue 
to do so as long as (1) its actions were permissible 
under the age or disability MSP provisions and 
(2) your plan does not take into account ESRD 
Medicare eligibility during the coordination 
period. 

Since you usually cannot get Medicare until 
the third month after the month in which you 
start a regular course of dialysis, you would have 
only your employer group health plan coverage 
during the first 3 months of dialysis-unless you 
are already enrolled in Medicare because of age 
or disability. However, if you undertake a course 
in self-dialysis training or receive a kidney 
transplant during the 3-month waiting period, part 
or all of this initial 3-month period would be 
included in the 18-month period during which 
Medicare may be secondary. 

Employer plans pay first for kidney treatment 
and other health services furnished during the 
1 8-month period. However, if the employer plan 
doesn't pay in full, Medicare may make 
secondary payments to supplement the amount 
paid by the employer plan. At the end of the 18- 
month period, Medicare becomes the primary 
payer. If you are covered by an employer group 
health plan during the 18-month period, you 
should tell the person who furnishes you with 
medical services so that the services can be billed 
correctly. 

If you have more than one period of Medicare 
enrollment based on kidney disease, there is a 
separate coordination period for each period of 
Medicare enrollment. For instance, if you receive 
a kidney transplant which is successful for at 
least 36 months, your Medicare protection ends 
as indicated above under When Medicare 
Protection Ends. If after the 36-month period you 
file for and again become enrolled in Medicare 
because you resume maintenance dialysis or 
receive another transplant, your Medicare 
coverage will be reinstated immediately, without 
a waiting period, and there will be a new 18- 
month coordination period if you are covered by 
an employer group health plan. 

If your employer plan will pay for all your 
health expenses, you may wish to wait until the 
1 8-month period is over to file for Medicare Part 
A and Part B enrollment. 



3 



Providers of Maintenance Dialysis 
and Transplant Surgery 

To receive Medicare payrolls., medk-aJ 
facilities must be specifically approved to provide 
maintenance dialysis or kidney transplant 
surgery — even if they already participate in 
Medicare to provide other healtb care services 
covered by the program. 

They must meet special health, safety, 
professional and staffing standards directly related 
to dialysis and kidney transplant services. And 
they must meet applicable federal, state, and local 
requirements. 

Your doctor or the facility can tell you whether 
a facility is approved by Medicare for payment 
of maintenance dialysis or transplant services. 

Coverage of Maintenance Dialysis 

This section explains coverage and payment 
for outpatient maintenance dialysis and the 
conditions under which inpatient dialysis is 
covered. 

Outpatient Dialysis 

Medicare Part B helps pay for outpatient 
maintenance dialysis treatments in any approved 
dialysis facility. Your coverage includes the costs 
of equipment, supplies, certain laboratory tests 
and other services associated with your treatment. 
Part B payments for outpatient maintenance 
dialysis furnished in the facility are always made 
to the facility. 

Medicare pays the facility for dialysis-related 
services based on a per treatment rate that is set 
in advance. This rate is the facility's composite 
rate. The facility may charge you only 20 percent 
of this rate. For example, if you have already 
met the $100 deductible and the composite rate 
is $130 per treatment, Part B pays the facility 80 
percent of $130 (or $104). Medicare cannot pay 
the remaining 20 percent of the charge (or $26). 
You are responsible for the 20 percent 
coinsurance charge. 

In addition to those dialysis-related services 
included in the composite rate, dialysis facilities 
may provide and bill separately for certain other 
services. Many of the laboratory tests you get, 
for example, may be included as part of the 
facility's maintenance dialysis services. But, if 
you need additional tests, they can be covered as 



facility services, independent laboratory services, 
m 3S mip&feas kxsjH&j services. For the services 
noi u>i !udrd m the composite rate, you are 
resp^n <Me for * 20 percent coinsurance charge. 

Far mmz information on covered services, see 
He sections on doctors services, outpatient 
hospital services, and other services and supplies 
in Your Medicare Handbook. 

Dialysis Patients Who Travel: If you are a 

dialysis patient and plan to travel, you should 
make arrangements for dialysis care along the 
route of your trip before you travel away from 
your usual dialysis facility. You are responsible 
for ensuring that an approved dialysis facility 
along the way has space and time available for 
your care, and that the physician and other 
medical personnel at the facility have enough 
information about you to treat you properly. Your 
facility will assist you in making the necessary 
inquiries. 

When you plan your trip, take into account the 
location of Medicare approved dialysis facilities. 
There are over 2,100 facilities around the country. 
Your facility, ESRD network (see page 10), or 
local organization should be able to help you get 
the names and addresses of those facilities. 

NOTE: If you get your dialysis services either 
from a Method II supplier or from a health 
maintenance organization (HMO), ask your 
supplier or HMO to assist you in getting dialysis 
while on travel. You may be responsible for your 
own dialysis treatment costs. 

In general, Medicare will pay only for hospital 
or medical care received in the United States. 

Inpatient Dialysis 

Generally, maintenance dialysis treatments are 
covered on an outpatient basis. But if you are 
admitted to a hospital because your medical 
condition requires the availability of other 
specialized hospital services on an inpatient basis, 
your maintenance dialysis treatments would be 
covered by Part A as part of the costs of your 
covered inpatient hospital stay. Please see Your 
Medicare Handbook for more information about 
the coverage of inpatient hospital care. 



Doctor's Services and 
Maintenance Dialysis 

Doctors services are covered by Medicare Part 
B. While you are on maintenance dialysis, Part 
B can pay for your doctor's services in the 
following ways. 

Outpatient Doctor's Services 

Medicare pays benefits for all doctor's services 
related to outpatient maintenance dialysis. 
Medicare carriers pay doctors on a monthly basis 
for the kidney disease-related services they 
provide to each patient. The same monthly 
amount is paid for each patient the doctor 
supervises, regardless of whether the patient 
dialyzes at home or as an outpatient in an end- 
stage renal disease (ESRD) facility. Using this 
method of physician payment, Part B pays 80 
percent of the monthly fee, minus any part of the 
$100 deductible you have not met. If your doctor 
accepts assignment, Medicare payment is made 
directly to him or her; otherwise, you receive the 
payment. 

Inpatient Doctor's Services 

If you are hospitalized, your doctor has a choice 
of two methods of payment for furnishing services 
to you as an inpatient. Your doctor may choose 
to continue to receive the monthly payment, in 
which case you cannot be billed for any additional 
amounts. Or, your doctor can choose to bill 
separately for the inpatient services, which 
Medicare will pay for in the manner described in 
Your Medicare Handbook. In this case, your 
doctor's monthly payment will be reduced based 
on the number of days you are hospitalized. 

Self-Dialysis Training 

Self-dialysis training is covered by Medicare 
Part B on an outpatient basis. 

Coverage of self-dialysis training includes your 
instruction and instruction for the person who 
will assist you with maintenance self-dialysis at 
home. Part B also covers the maintenance 
dialysis treatment and laboratory tests and other 
services and supplies associated with the 
treatment. 

By law, Medicare cannot cover the cost of paid 
dialysis aides to assist self-dialysis patients at 
home. Nor can Medicare cover the costs of wages 



that you and your assistant lose while being 
trained, or the cost of lodging during treatment. 

Payment rates for self -dialysis training sessions 
are higher than those for maintenance dialysis 
treatments. And charges vary from one dialysis 
facility to another, depending upon type of facility 
and its geographic location. But regardless of 
variations in charges, this is how Medicare 
payment works: If you are charged $150 per 
session and have already met the annual 
deductible, Part B will pay 80 percent of the 
training rate (or $120 per session). Medicare 
cannot pay the remaining 20 percent (or $30 per 
session). 

For the services of the doctor who is 
conducting your self-dialysis training, the 
maximum total charge Part B will approve is 
$500. If your doctor charges $500, Part B would 
pay 80 percent of $500 (or $400) if you have 
already met the deductible. Medicare cannot pay 
the remaining 20 percent (or $100), or any 
charges above the Medicare approved amount. 

Retraining for self-dialysis— for example, in 
the use of new equipment— is also covered by 
Medicare Part B on an outpatient basis. 

Home Dialysis 

Medicare Part B covers home dialysis 
equipment, all necessary supplies, and a wide 
range of home support services. Home dialysis 
includes home hemodialysis, home intermittent 
peritoneal dialysis (IPD), home continuous 
cycling peritoneal dialysis (CCPD), and home 
continuous ambulatory peritoneal dialysis 
(CAPD). 

Usually, drugs used in your home are not 
covered unless a doctor administers them. 
However, certain drugs for home dialysis patients 
are covered even though a doctor is not present. 
The most common of these are heparin, the 
antidote for heparin when medically indicated, 
and topical anesthetics. In addition, Part B covers 
the self-administration of the drug Epoetin alfa 
(EPO), by you or your care giver, subject to 
standards established for this drug's safe and 
effective use. Blood or packed red blood cells 
cannot be covered for home dialysis unless your 
doctor administers it or personally directs its 
administration, or if the blood is needed to prime 
your dialysis equipment (see How Medicare Pays 
for Blood, page 7). 



Payment Options Under Home Dialysis 

If you dialyze at home, you can choose between 
two payment options: Method I or Method II. 
These options are described below. To make a 
choice, you complete the Beneficiary Selection 
Form HCFA-382, sign it and return it to the 
facility supervising your care. You can get a 
copy of Form-382 from your dialysis facility. 
Once you make your initial choice, you must 
continue under that option until December 31 of 
that year. You can change from one method to 
the other by filing a new Form-382 at any time, 
but the change does not go into effect until the 
following January 1. It is important to remember 
that choosing Method I or Method II does not in 
any way prevent you from returning to treatment 
in a center, selecting another kind of treatment 
for ESRD care, or choosing to associate with 
another facility. 

Method I: The Composite Rate 

If you choose Method I your dialysis facility 
is responsible for providing all services, 
equipment and supplies necessary for home 
dialysis. Medicare pays the facility directly 
for these items and services at a predetermined 
composite rate. Under this arrangement, you 
are responsible for paying the $100 deductible 
and the 20 percent coinsurance on the Medicare 
rate to the facility. 

Method II: Dealing Directly with a Supplier 

If you choose Method II, you must deal directly 
with a single supplier to obtain all of your 
home dialysis equipment and supplies. You 
must have only one supplier. Your supplier 
must have a written agreement with a dialysis 
facility to guarantee that you will receive all 
necessary backup and home dialysis support 
services. Your supplier must accept 
assignment of Medicare benefits (that is, the 
supplier must accept Medicare's allowance for 
its charges). If your supplier does not accept 
assignment, Medicare will not pay anything, 
and you will be responsible for the supplier's 
entire bill. If your supplier accepts assignment, 
you are responsible for any unmet part of the 
$100 deductible and for 20 percent coinsurance 
of the approved charges for these items and 
services. There is a national payment limit 
under Method II, and no supplier may charge 
more than this limit. 



Under both methods, you must receive your 
home dialysis support services from your facility, 
for which Medicare pays the facility directly. 

Home Dialysis Equipment 

Under Method I, all home dialysis equipment 
and equipment- related services are covered under 
the facility's composite rate payment. Under 
Method II, Part B also covers rental or purchase 
of dialysis equipment for home use. Delivery, 
installation and maintenance charges are included 
as part of this benefit. 

Whether you rent or buy dialysis equipment, 
Part B usually makes monthly payments. If you 
buy dialysis equipment, the monthly Part B 
payment includes any reasonable interest or 
carrying charges that may be part of an 
installment purchase agreement with the supplier 
of the equipment. 

After the $100 deductible, Part B pays 80 
percent of the approved monthly rental charge or 
the approved monthly installment purchase price 
for your home dialysis equipment. 

Part B payments for your home dialysis 
equipment can continue as long as you need to 
be dialyzed at home. If your need for home 
dialysis stops, Part B payments also stop. For 
example, if you no longer need to be dialyzed 
because your kidney transplant surgery was 
successful, then Part B payments for your home 
dialysis equipment would stop. 

If you purchase your dialysis equipment, Part 
B payments always stop when the Medicare 
approved purchase price is reached. 

Home Dialysis Supplies 

Part B covers all supplies necessary to perform 
home dialysis. This includes disposable items 
such as alcohol wipes, sterile drapes and rubber 
gloves, forceps, scissors, and topical anesthetics. 
Under Method I, all home dialysis supplies are 
covered under the facility's composite rate 
payment. Under Method II, after the $100 
deductible, Part B pays 80 percent of the approved 
charges for all covered items. 

Home Dialysis Support Services 

Part B covers periodic support services, 
furnished by an approved hospital or facility, 
which are necessary to help you remain on home 
dialysis. After your doctor approves the plan of 
treatment, such support services may include 



visits by trained hospital or facility personnel to 
periodically monitor your home dialysis and to 
assist in emergencies when necessary. Part B 
also covers the services of qualified facility or 
hospital personnel to inspect your dialysis 
equipment and to test your water supply. 

Under Method I, all home dialysis support 
services are covered under the facility's 
composite rate payment. Under Method II, Part 
B pays directly to the facility 80 percent of the 
approved charges for all covered services after 
the $100 deductible has been met. 

Kidney Transplant Surgery 

Both parts of Medicare help pay for kidney 
transplant surgery. 

What Hospital Insurance (Part A) Pays For 

Medicare Part A covers your inpatient hospital 
services in an approved hospital when you are 
admitted for kidney transplant surgery. (See page 
1 for more information about the Medicare 
inpatient hospital benefit.) Part A also covers 
hospital services in preparation for your kidney 
transplant. This includes the Kidney Registry 
fee and services such as laboratory and other tests 
that are required to evaluate your medical 
condition and the medical conditions of potential 
kidney donors. These preparatory services are 
covered whether they are done by the approved 
hospital where your transplant surgery will take 
place or by another hospital that participates in 
Medicare. If there is no kidney donor, the costs 
of obtaining a suitable kidney for your transplant 
surgery are also covered. 

Part A pays the full cost of care for a person 
who donates a kidney for your transplant surgery. 
This includes all reasonable preparatory, 
operation, and postoperative recovery expenses 
connected with the donation. There is no 
deductible or daily amount for your donor's 
hospital stay. The inpatient hospital stay does 
not qualify your donor for any Medicare benefits 
not associated with the kidney donation. But, 
Medicare Part A will pay for any additional 
inpatient hospital care your donor might need if 
complications result directly from the kidney 
donation. Medicare does not pay for kidneys; the 
purchase of human organs is prohibited by law. 

Medicare Part A payments are made directly 
to the hospital. 



What Medical Insurance (Part B) Pays For 

Medicare Part B covers your surgeon's services 
for performing the kidney transplant operation. 
This includes pre-operative care, the surgical 
procedure, and follow-up care. Part B also covers 
doctor's services provided to your kidney donor 
during his or her inpatient hospital stay while 
you are receiving a kidney transplant. 

After you meet the $100 Part B deductible, 
Part B pays 80 percent of the approved charge 
for your surgeon's services to you. 

There are certain limits on the amount your 
doctor can charge you, even if your doctor does 
not take assignment. On unassigned claims, you 
are only responsible for the part of your bill that 
is more than the Medicare-approved amount — 
up to the limit Medicare allows your doctor to 
charge. Look in Your Medicare Handbook for 
more information about "assignment" and limits 
on charges. 

There is no deductible or coinsurance for 
doctor's services provided to your kidney donor. 

Medicare pays for your immunosuppressive 
drugs for a period of one year following your 
discharge from the transplant hospital. This 
benefit is subject to the Part B deductible and 
coinsurance provisions. 

How Medicare Pays for Blood 

Both parts of Medicare can help pay for whole 
blood or units of packed red blood cells, blood 
components, and the cost of blood processing 
and administration after the Part A and B blood 
deductibles are met. 

Medicare Part A does not pay for the first three 
units of whole blood or units of packed red cells 
that you receive, during a benefit period, as an 
inpatient of a hospital or skilled nursing facility. 
You are responsible for the first three units of 
whole blood or packed red cells. You have the 
option of paying the hospital's charges for the 
blood or packed red cells or arranging for it to 
be replaced. 

If you choose to have the blood replaced, you 
can arrange for another person or an organization 
to replace it for you. A hospital or skilled nursing 
facility cannot charge you for any of the first 
three pints of blood you have replaced or have 
arranged to replace. Also, if the provider obtained 
blood or red cells at no charge other than a 
processing or service charge, the blood or red 
cells is deemed to have been replaced. 



If you have paid for or replaced some units of 
5 lood under Medicare Part B during the calendar 
/ear, you do not have to pay for or replace thtf 
lumber of units again under Part A. 
Except for replaced whole blood or packed red 
ells, Medicare Part B does not pay for the first 
three units of whole blood or units of packed red 
cells that are furnished in a calendar year. 
NOTE: The blood deductible does not apply to 
other blood components such as platelets, fi- 
brinogen, plasma, gamma globulin, and serum 
albumin, or to the cost of processing, storing, 
and administering blood. 
After you have met the $100 deductible, Part 
B pays 80 percent of the approved charges for 
blood starting with the fourth pint in a calendar 
year. 

Medicare does not cover blood in connection 
with self-dialysis at home unless it is provided 
as part of a doctor's service or is needed solely 
for the purpose of priming the dialysis equipment. 

If you have paid for or replaced blood under 
Medicare Part A during the calendar year, you 
do not have to do so again under Part B. 

What Medicare Does Not Cover 

The following list shows some of the services 
and supplies that Medicare does not cover in 
connection with dialysis and transplant services^ 
Your Medicare Handbook lists other services and 
supplies which are not covered by Medicare (see 
"What Medicare Does Not Cover"). 

• Ambulance or other transportation costs to a 
facility for routine outpatient maintenance 
dialysis 

• Dialysis aides' services to assist in home 
dialysis 

• Inpatient hospital and skilled nursing facility 
costs when the stay is solely for maintenance 
dialysis 

• Lodging costs when an outpatient dialysis 
facility is not near your home 

• Wage losses to you and your dialysis partner 
during self-dialysis training 



Other Payment Sources 

li vro teve i^ffc '»t Fraction 
bcahh a«« the Vticnm. Administration, the 
Indian Ffcahfc Service, a federal employee s health 
Dlaiu CHAMFUS or another source, it also may 
help pay for services you need for the treatment 
of permanent kidney failure. 

In most states there are agencies that help with 
some of the medical expenses Medicare does not 
cover Some states have Kidney Commissions 
that assist people in meeting the expenses 
Medicare cannot pay. And most states have a 
Medicaid program that helps pay medical 
expenses in cases of serious financial need. 

Under certain circumstances, employer group 
health plans, including federal employee health 
plans, will be required to pay their benefits before 
Medicare pays (see page 3). 



If You Have a Complaint 

If you have a grievance or complaint about the 
quality or adequacy of care you are getting, 
discuss your problem with your doctor, nurse or 
facility administrator first. If this discussion does 
not resolve your problem, you have the right to 
file a grievance with the ESRD Network in your 
area. You can find your Network in the listing 
beginning on page 9. Your social worker can 
also give you more information about how the 
Network grievance system works. 

For Additional Help 

If you have questions about kidney dialysis or 
transplant services in your area, contact your local 
Network Organization (see page 9). 

If you have any questions about Medicare, 
contact your nearest Social Security office or the 
Medicare insurance carrier in your area lne 
carriers are listed in the back of Your Medicare 
Handbook, which is available from the Social 
Security office. 




ESRD Network Organizations 

The ESRD Network Organizations are established by law and are organized into 18 
geographic areas throughout the United States, Guam, Puerto Rico and American Samoa. 
The Network Organizations, listed below, are comprised of hospitals, kidney dialysis 
units, transplant centers, medical professionals and patients. The organizations are 
responsible for developing criteria and standards for the quality and appropriateness of 
patient care; assessing the appropriateness of treatment methods for patients; and making 
sure that the Renal Registry is maintained. 



States of Maine, New Hampshire, 
Vermont, Massachusetts, Connecticut 
and Rhode Island 

(ESRD Network Organization No. 1) 

ESRD Network of New England 
951 Elm Street 

New Haven, Connecticut 065 1 1 
(203) 387-9332 

State of New York 

(ESRD Network Organization No. 2) 

ESRD Network of New York, Inc. 
2 East 103rd Street, Room 456 
New York, New York 10029 
(212) 289-4524 

State of New Jersey and Territories of 
Puerto Rico and U.S. Virgin Islands 

(ESRD Network Organization No. 3) 

TransAtlantic Renal Council 
Ryders Office Plaza 
1 80 Tices Lane 

East Brunswick, New Jersey 08816 
(908) 846-6060 

States of Pennsylvania and Delaware 

(ESRD Network Organization No. 4) 

University of Pittsburgh Medical Center 
200 Lothrop Street 
Pittsburgh, Pennsylvania 15213-2582 
(412) 647-3428 



District of Columbia and States of 
Maryland, Virginia, and West Virginia 

(ESRD Network Organization No. 5) 

Mid-Atlantic Renal Coalition 
1527 Huguenot Road 
Midlothian, Virginia 231 13 
(804) 794-3757 

States of Georgia, North Carolina and 
South Carolina 

(ESRD Network Organization No. 6) 

Southeastern Kidney Council, Inc. 
Lake Plaza East 

900 Ridgefield Drive, Suite 150 
Raleigh, North Carolina 27609 
(919) 876-7545 

State of Florida 

(ESRD Network Organization No. 7) 

ESRD Network of Florida, Inc. 
1 Davis Boulevard, Suite 304 
Tampa, Florida 33606 
(813) 251-8686 

States of Alabama, Mississippi and 
Tennessee 

(ESRD Network Organization No. 8) 

Network Eight, Incorporated 
660 Katherine Drive, Suite 306 
Flowood, Mississippi 39208 
(601) 936-9260 



9 



States of Kentucky, Indiana and Ohio 

(ESRD Network Organization No. 9) 

Tri State Renal Network, Inc. 
91 1 E. 86th Street, Suite 202 
Indianapolis, Indiana 46240-1858 
(317) 257-8265 

State of Illinois 

(ESRD Network Organization No. 10) 

Crescent Counties Foundation for 
Medical Care 

1001 Warrenville Road, Suite 500 
Lisle, Illinois 60532-9735 
(708) 769-9600 

States of Michigan, Minnesota, Wisconsin, 
North Dakota and South Dakota 

(ESRD Network Organization No. 1 1) 

Renal Network of the Upper Mid-West, Inc. 
Central Office 

970 Raymond Avenue, Suite 205 
St. Paul, Minnesota 551 14 
(612) 644-9877 

States of Missouri, Iowa, Nebraska and 
Kansas 

(ESRD Network Organization No. 12) 

ESRD Network Organization No. 12 
600 Broadway, Suite 590 
Kansas City, Missouri 64105-1536 
(816) 221-0477 

States of Arkansas, Louisiana and 
Oklahoma 

(ESRD Network Organization No. 13) 

ESRD Network Organization No. 13 
625 NW 13th Street 

Oklahoma City, Oklahoma 73103-2232 
(405) 523-2127 



State of Texas 

(ESRD Network Organization No. 14) 

ESRD Network of Texas, Inc. 
1755 N. Collins Blvd., Suite 221 
Richardson, Texas 75080 
(214) 669-3311 

States of New Mexico, Colorado, Wyoming, 
Utah, Arizona and Nevada 

(ESRD Network Organization No. 15) 

Intermountain ESRD Network, Inc. 
Penn Center 

1301 Pennsylvania Street 
Suite 220 

Denver, Colorado 80203-5012 
(303) 831-8818 

States of Montana, Alaska, Idaho, Oregon 
and Washington 

(ESRD Network Organization No. 16) 

Northwest Renal Network 
2701 First Avenue, Suite 430 
Seattle, Washington 98121 
(206) 448-1803 

Northern California, Hawaii, Pacific Trust 
Territory, Guam and American Samoa 

(ESRD Network Organization No. 17) 

Transpacific ESRD Network 
#28 Issaquah Dock 
Waldo Point Marina 
Sausalito, California 94965 
(415) 331-1545 

Southern California 

(ESRD Network Organization No. 18) 

ESRD Network Organization No. 18 
6255 Sunset Blvd., Suite 221 1 
Hollywood, California 90028 
(213) 962-2020 



10 



•U.S. Government Printing Office: 1995— 394-437/30497 



OTHER PUBLICATIONS ABOUT MEDICARE 



Guide to Health Insurance for People with Medicare $18B) 

Discusses what Medicare pays and does not pay, types 
of private health insurance to supplement Medicare and 
gives hints on shopping for private health insurance. 

Medicare: Coverage for Second Surgical Opinion (521B) 

Explains the importance of getting a second opinion 
for non-emergency surgery, describes Medicare coverage 
of costs, and gives suggestions for locating a specialist in 
your area. 

Medicare: Hospice Benefits (591B) 

Describes the scope of medical and support services 
available to Medicare beneficiaries with terminal illnesses. 

Medicare and Managed Care Plans (592B) 

Describes the health services available to beneficia- 
ries from health maintenance organizations (HMOs). 

Medicare and Other Health Benefits (593B) 

Answers the question "Who pays first?" Explains the 
special rules that apply to Medicare beneficiaries who have 
other health plan coverage. 



Manual De Medicare (595B) 

The Spanish language handbook. 

Medicare: Savings for Qualified Beneficiaries (596B) 

Explains that low-income beneficiaries may be able 
to get help paying Medicare costs. 

Medicare and Your Physician's Bill (520B) 

Explains how Medicare pays for doctor services and 
how Medicare determines how much it will pay. 

Medicare and Advance Directives (519B) 

Tells about two commonly used advance directives, 
the Living Will and the Durable Power of Attorney for 
Health Care. 

Continuous Improvement (637 A) 

Tells about our plan to improve service to our 
beneficiaries. 

■ 

aalflrnoro. Maryjg;vi 21244 „_j 



To order a free copy of one or more of these publications, fill out and mail this order form to: 
Consumer Information Center. Department 33 
Pueblo, CO 81009 

Supplies may be limited. Allow 6 to X weeks for deliver*. 



Please cut lu re and mail 



Check the booklets you want, fill in your name and address, and 
send this order form to: Consumer Information Center, 
Department 33, Pueblo. CO 81009. 

j Guide to Health Insurance for People with Medicare (5 1 8B) 

J Medicare: Coverage for Second Surgical Opinion (521 B) 

j Medicare: Hospice Benefits (591 B) 

-j Medicare and Managed Care Plans (592B) 

j Medicare and Other Health Benefits (593B) 

j Manual De Medicare (595B) 

-j Medicare: Savings for Qualified Beneficiaries (596B) 
j Medicare and Your Physician' s Bill (520B) 
j Medicare and Advance Directives (51 9B) 
□ Continuous Improvement (637 A) 



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